What is the late pathophysiology in a patient with an open book pelvic injury and a devitalized area in the right thigh following a motor vehicle accident (MVA)?

From the Guidelines

The late pathophysiology of a patient involved in an MVA with an open book pelvic injury and devitalized area in the right thigh is D. Increase in cortisol. In the late phase following such trauma, the body's stress response leads to elevated cortisol levels as part of the neuroendocrine response to severe injury, as discussed in the management of bleeding and coagulopathy following major trauma 1. This increase in cortisol represents the body's attempt to maintain homeostasis by mobilizing energy reserves, promoting gluconeogenesis, and modulating the inflammatory response. While the initial response to trauma includes increased heart rate and other compensatory mechanisms, the question specifically asks about late pathophysiology. The sustained elevation of cortisol is characteristic of the prolonged stress response seen in severe trauma cases like pelvic fractures with tissue devitalization, which can lead to significant morbidity and mortality if not properly managed, as highlighted in the guidelines for pelvic trauma management 1. This hypercortisolemia helps maintain blood pressure and glucose levels but can eventually lead to immunosuppression, protein catabolism, and impaired wound healing if prolonged. The open book pelvic fracture creates potential space for significant blood loss, while the devitalized thigh tissue presents risk for infection and further metabolic derangement, both contributing to the ongoing stress response and cortisol elevation, as noted in the updated European guideline for management of bleeding and coagulopathy following major trauma 1. Key considerations in managing such patients include early detection of pelvic hemorrhage, initial efforts to reduce disruption and stabilize the pelvis, and containment of bleeding, as well as the potential use of angiography and embolization to control arterial bleeding, as discussed in the evidence 1. Overall, the management of patients with severe pelvic injuries requires a multidisciplinary approach, with attention to the potential for late pathophysiological changes, including the increase in cortisol levels.

From the Research

Late Pathophysiology of Open Book Pelvic Injury

The late pathophysiology of open book pelvic injury involves several factors, including:

• Increase in pelvic volume, which facilitates blood diffusion from the parietal pelvic vascular network 2
• Venous dilaceration of the ilio-lumbar vein, which can occur due to the transversal disposition of the ilio-lumbar pedicle with regard to the sacro-iliac joint 2
• Potential for hemorrhage and hemodynamic instability, which can lead to increased heart rate and other systemic responses 3, 4
• Possible increase in venous tone as a result of the injury and subsequent treatment 2

Systemic Responses

In terms of systemic responses, the late pathophysiology of open book pelvic injury may involve:

• Increase in heart rate (HR) as a result of hemorrhage and hemodynamic instability 3, 4
• Potential changes in systemic resistance and venous tone, although these are not directly addressed in the provided studies
• Increase in cortisol levels as a result of the stress response to injury, although this is not specifically mentioned in the provided studies

Relevant Findings

Relevant findings from the provided studies include:

• The importance of prompt recognition and treatment of open book pelvic fractures to prevent complications and improve outcomes 3, 4
• The use of anterior and posterior fixation in the treatment of open book pelvic ring injuries, although the optimal approach is still a matter of debate 5
• The potential for long-term functional impairment and neurological deficits, such as male impotence, following open book pelvic injury 4